Summary: For the last 6 years, Anne Nedrow, MD, has been at the center of the most robust, multi-disciplinary, inter-institutional complementary and integrative clinical and research action in the United States. From her Portland, Oregon base at Oregon Health & Science University, Nedrow has worked closely with leaders of that city's accredited colleges of chiropractic, naturopathic and acupuncture and Oriental medicine. In doing so, Nedrow has helped create numerous, precedent-setting relationships for members of complementary healthcare disciplines. Here is the Integrator interview with one of integrative medicine's leading integrators.

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Introduction: Breaking the "Color Barrier"

Last spring I had an opportunity to participate in a phone conference with members of the Clinical Working Group (CWG) of a consortium of conventional medical schools. The clinicians on the call were exploring efforts to clinically integrate complementary and conventional care in medical school-sponsored settings.

Anne Nedrow, MD

I had a happy surprise on the call. It was one of those little historic moments when one realizes that we are slowly breaking down the guild barriers and prejudice that separate the distinct disciplines in medicine. Anne Nedrow, MD, had everything to do with that moment.

The consortium of which I speak was the 39 member Consortium of Academic Health Centers for Integrative Medicine(CAHCIM). The secretary of that Consortium is Nedrow. She holds that office via her representation of Oregon Health Science University (OHSU) on the CAHCIM steering committee. Nedrow is an OHSU associate professor in medicine and obstetrics-gynecology who also wears the title of medical director of integrative health and women's primary care for an OHSU integrative clinic.

Nedrow wasn't, however, on the conference call. The person who represented OHSU on the Clinical Working Group call was oneLynne Shinto. Shinto is a clinician-researcher Nedrow had appointed to that slot. Shinto is a physician with an MPH, and an NIH-funded researcher. She holds clinical appointments in both Nedrow's integrative clinic and at a separate integrated neurology clinic at OHSU. Her role with CAHCIM seemed particularly appropriate.

What brought my smile of pleasure in a historic threshold being crossed was that Dr. Shinto happens to not be a medical doctor. She is a naturopathic physician: Lynne Shinto, ND, MPH. As a CWG participant, Shinto became the
first member of a non-conventional discipline to participate in the
Consortium's annual meeting last Fall. Like a person of color or a Jewish person being accepted into a Downtown business club in the United States of the 1960s, Shinto's participation in CAHCIM broke a cultural barrier.

While Shinto's own wits and other relationships and accomplishments prepared her for her precedent-setting positions, both of Shinto's clinical appointments - which set up the CAHCIM role - came by Nedrow literally putting her medical license on the line.

For a newsletter called the Integrator, it seemed a good story to speak with Nedrow about her own work in integrating the disciplines in Portland, Oregon, where she has done her best to make the most of a unique situation in the United States. Portland is the only metropolitan area which boasts a school of medicine (OHSU), a naturopathic medical school (National College of Natural Medicine-which also has an acupuncture program), a chiropractic school (Western States Chiropractic College- which also has a massage program) and an acupuncture and Oriental medicine school (Oregon College of Acupuncture and Oriental Medicine). I spoke with Nedrow in mid-September.

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Integrator: How did you get interested in integrative medicine?

Nedrow: I had been doing community medicine with Providence (Health System) in Portland. After 10 years of practice, I didn't like being an internist anymore. I had begun to explore other things. I took the botanical course Columbia University offered. I was recruited for a women's primary care position at OHSU in about 2000. They had to take the integrative medicine with me. I entered the first (associate fellowship in integrative medicine) group at the University of Arizona. OHSU paid for the fellowship. I thought that with integrative medicine I was finding my way out of being an internist. I realized I was finding that I liked doing it again. I am one of the few internists I know who still loves her job after 22 years.

Integrator: Talk about your relationships with complementary medicine practitioners and the other colleges in Portland.

Nedrow: It's been great. It started with the (R-25 NIH) education grant we received in 2001. In Portland at that time there was already a comfort level between the professions and between the schools. There were two earlier NIH grants, and the relationships went back even further. I found friendships with many of the providers. It was a natural to move them into clinical roles.

Integrator: It's all been smooth sailing ...?

Nedrow: There have been bumps. We've had issues getting some practitioners to do basic things like filling out a medical record in a timely way. We also made a big shift in our way of paying, from salary to revenue sharing. They need to be self-starters. We had one who didn't do well at that. We have a financial situation now with revenue sharing where we can't go in the hole.

Integrator: What's the revenue split?

Nedrow: We think it's very generous - 60/40 with 60% going to them. There are strains even with this. They have to pay for parking. They have no benefits. And I have to fight hard with my medical colleagues each year to keep it at 60/40.

Integrator: How many clinicians from the other disciplines does OHSU have now?

Nedrow: Lynne (Shinto) works in both my clinic and the neurology clinic which we just started up. She's a gem. She's so well-funded (via grants). We have an acupuncturist from OCOM who also works in both clinics. We had a chiropractor who didn't turn out to be enough of a promoter.Integrator: What are the key characteristics you look for in a practitioner from one of these disciplines?

Nedrow: Excellent communication skills. They need to be able to do conflict, know how to approach negotiation in healthy ways. They need to be able to understand and respect privileges, what they can do and what they can't do. Clearly they can do better if they understand medical records and medical language. That's why, with acupuncturists, for instance, we are working with those whose have the (DAOM-Doctor of Acupuncture and Oriental Medicine). They have more understanding of medical thinking.

Consortium of Academic Health Centers for Integrative Medicine - Nedrow serves as a member of the executive committee

Integrator: Was there any resistance to Lynne being on the Clinical Working Group for the Consortium of Academic Health Centers for Integrative Medicine?

Nedrow: She was on the Research Working Group before. Now we actually have two naturopathic physicians representing OHSU. The other is a representative to the Research Working Group. The Consortium also has another naturopathic physician on the Clinical Working Group out of Yale.Integrator: Yeah Ather, Ather Ali, another ND, MPH. Any chiropractors or acupuncturists?

Nedrow: No, other than James Dillard. He's an MD and a chiropractor and an acupuncturist. I think there will be more as they get on the faculties of the academic health centers.Integrator: Your research has taken off since OHSU's first multi-institutional, multi-disciplinary R-25 grant in 2001 hasn't it?

Nedrow: I'm now on 5 NIH grants currently. The OHSU R25 is in the final year. Two of my
current grants are the so-called "Reverse R-25" with OCOM and
Western States. One is an R21 with NCNM. OHSU also received a second education grant from the NIH for which I represent
mind-body education. We formed the
Oregon Collaborative for Complementary and Integrative Medicine under that
grant. Now the "reverse" grants are to help develop more evidence-based content in
the programs at [the CAM school] programs. We're very proud that
all 3 CAM schools were awarded these grants.Integrator: You said something when we had you at the National Education Dialogue to Advance Integrated Health Care meeting in 2005 that I have frequently repeated to others in the complementary healthcare fields. So many of the challenges between the licensed complementary healthcare disciplines and conventional medicine are actually challenges between each of those disciplines, too. The guild issues come up. You said something to the effect that the nice thing about working with educators rather than political leaders, say, from the different disciplines is that, while you may have differences in practice philosophy or approach, as educators you share core mission and values, and that when tough spots come up, shared educational values and vision can guide resolution.

Portland, Oregon location of OHSU's integrative women's health clinic

Nedrow: That's been my experience.

Integrator: It's been useful to me with my organizing work - so thanks for that! You mentioned that you are choosing to take on a new business degree program? What is that about?

Nedrow: It's a fast-track MBA through Babson College in Boston. Two years, online plus 8 face-to-face meetings. I'm doing it because I need some more skills to do what I want to do. The things I am clinically interested in and passionate about are all time-based and that's not what pays in medicine. Most complementary and alternative medicine models are time-based care. You do a colonoscopy you get paid well. You counsel a person on behavioral change and you're not reimbursed for anything. We need to figure out new business models and new models of relationships to get things done. I picked this MBA at Babson for its entrepreneurial focus. It's all about thinking outside the box.Integrator: What is the thing you have most wanted to do that you haven't been able to accomplish yet?

Nedrow: I have wanted to build a cohesiveness among the MDs at OHSU for broadening the integrative effort. It's not that they don't want it. We'd like to do it. They'd like to do it. But that's as far as it goes. Actually moving it must be financially based.

Integrator: So the economic model isn't there ...?

Nedrow: This is not unique to OHSU. We are all trying to find out how to finance
time-based care, such as primary care or integrative medicine.Integrator: Your beautiful clinical facility beside the river will help lure consumers and give potentially referring physicians comfort, I would think. But for you, personally, what would you most like?

Nedrow: Our whole strategy has been to embed the services through OHSU, not
to have separate clinics. This is integrative health. I am not sure exactly where I see myself in
two years, but I think this work needs a leader.

Integrator: From my experience, you will not be easy to replace. But maybe now that some of the barriers are down - thanks in part to your courage - there will be a larger pool of leaders who will be able to follow.

Nedrow: This is the right direction for medicine. A mentor said a long time ago that if you know the right thing to do, you should just go with it. Tracy Kidder, in Mountains Beyond Mountains, tells a story of what one person with a passion can do if they know what they want. This is the right thing for health care.

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